Name: Date of Birth:
Address: Phone # ( )
In case of emergency, I would like CrossFit PTC to Call:
Phone# ( ) Work phone # ( )
This person is my: (parent, friend, spouse, etc.):
May we add you to our mailing list to keep you updated on CrossFit PTC functions? ( YES / NO )
Waiver and Release of Liability
303 Kelly Drive, Suite 8&9
Peachtree City, GA 30269
Express assumption of risk: I am aware that there are significant risks involved in all aspects of physical training.
These risks include, but are not limited to: falls which can result in serious injury or death, injury or death due to
negligence on the part of myself, my training partner, or other people around me, injury or death due to improper use
or failure of equipment. I am aware that any of these above mentioned risks may result in serious injury or death to
myself and/or my partner(s). I affirm that I have read the article on rhabdomyolysis that is on the bulletin board.
I willingly assume full responsibility for the risks that I am exposing myself to and accept full
responsibility for any injury or death that may result from participation in any activity or class while at CrossFit
PTC. I, the undersigned acknowledge that I have no physical impairments or illnesses that will endanger
myself or others.
Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am
willingly and voluntarily participating in the activities available at CrossFit PTC, I hereby release CrossFit PTC,
their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of
action, which are related to, arise out of, or are in any way connected with my participation in this activity, including
those allegedly attributed to the negligent acts or omissions of the above mentioned parties.
This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or
transferees. If any portion of this agreement is held invalid, the remainder of the agreement shall remain in full
force and effect.
If I am signing on behalf of a minor child, I also give full permission for any person connected with
CrossFit PTC to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to
call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary
for the well being of the child.
Images: I authorize CrossFit PTC to take pictures and movies of me and use them on their website and other
promotional and educational materials.
Indemnification: I recognize that there is risk involved in the types of activities offered by CrossFit PTC. I
therefore accept financial responsibility for any injury that the I may cause either to myself or to others. Should the
above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce
this agreement, I will reimburse them for such fees and costs. I agree to indemnify and hold harmless CrossFit PTC,
their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage
to property that may result from my negligent or intentional act or omission while participating in activities offered
by CrossFit PTC.
I have read and understood the foregoing and I understand that by signing it obligates me to indemnify the
parties named for any liability for injury or death of any person and damage to property caused by me. I
understand that by signing this form I am waiving valuable legal rights.
Signature of participant: Date:
If the participant is under the age of 18,
Signature of Parent or Guardian: Date:
(Parent/Guardian) Print Name: